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General NPI Number Information
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NPI Number | 1558304139
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Entity Type | Individual
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Provider Name | GARY L JENSEN MD
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Gender | Male
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Dates
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Enumeration Date | 06/13/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 255 E BONITA AVE
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City | POMONA
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State | CA
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Zip | 91767-1923
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Country | US
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Telephone | 909-450-0393
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Fax | 909-450-0394
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Provider Business Mailing Address
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Address Line | PO BOX 480033
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City | LOS ANGELES
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State | CA
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Zip | 90048-1033
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Country | US
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Telephone | 909-450-0393
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Fax | 909-450-0394
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | A43613
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License Number State | CA
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